Contemporary surgical management of synchronous colorectal liver metastases

Young-onset metastatic colorectal cancer: an opportunity and a vision for progress in cancer

Metastatic young-onset colorectal cancer (yo-CRC) is a distinct and aggressive disease subtype that is becoming increasingly prevalent worldwide with Australia leading the world in this trend. This article provides an evidence-based perspective, through the prism of authors' personal experience, to craft an effective pathway not only to deliver improved outcomes for the patients but also to reduce disparities and foster collaboration amongst the cancer-treating community and indeed patients. It highlights an opportunity to re-define, re-design, and create a model that is rewarding to patients and cancer-treating community. Although our focus is on the high unmet needs group of yo-CRC, this model has the potential to expand to other cancer types and care models. We analyse the unique epidemiological trends, challenges, and burdens, emphasising the need for tailored treatment approaches for younger patients with colorectal cancer especially in the metastatic setting. We identify current gaps in clinical practice and research. To improve real-world outcomes, we propose a conceptual framework to enhance clinician-patient communication and treatment planning. Central to our approach is the integration of a Registry of Incidence, Intervention, and Outcomes (RIIO), which enables real-time data collection and analysis, improving treatment personalisation and efficacy. This registry could revolutionise patient care and drive research innovation through enhanced data sharing and collaboration. We advocate for a patient-centric integrated care model that utilises all available therapies to maximise survival and quality of life. Our perspective underscores the urgent need for a paradigm shift in how yo-CRC is viewed, researched and managed, proposing a pathway to significantly enhanced outcomes. Whilst it is feasible to expand the concepts discussed here for all colorectal cancer and indeed all cancer types, we believe this approach is most relevant and acutely needed in yo-CRC setting for reasons detailed in the manuscript.

Advancement in the Management of Synchronous Colorectal Liver Metastasis: A Comprehensive Review of Surgical, Systemic, and Local Treatment Modalities

Synchronous colorectal liver metastases (sCRLMs) present a complex therapeutic challenge requiring multimodal management strategies due to their complex tumor biology, variable disease progression, and the need to balance oncologic control with liver function preservation. This systematic review evaluates recent advancements in surgical approaches, systemic therapies, and local treatment modalities. A comprehensive literature search was conducted across major databases (PubMed, EMBASE, and Cochrane) for studies published between 2013 and 2024. Studies evaluating surgical techniques, perioperative outcomes, systemic therapy integration, and local treatments for sCRLM were included. Quality assessment was performed using the Newcastle-Ottawa Scale for observational studies and the Cochrane risk-of-bias tool for randomized controlled trials (RCTs). Analysis of nine primary studies encompassing 3,856 patients revealed evolving treatment paradigms. This review includes English-language studies (2013-2024) on adult patients (≥18 years) with sCRLM, covering RCTs, cohort, and case-control studies reporting survival, perioperative outcomes, or quality of life (≥12 months follow-up). Exclusions include case reports (<10 patients), metachronous metastases, conference abstracts, reviews without data, unclear methodology, duplicates, and animal/in-vitro studies. Staged resection demonstrated superiority over the simultaneous approach in recent analyses (win ratio 1.59, 95%CI 1.47-1.71). This indicates that patients undergoing staged resection had a 59% higher likelihood of achieving better outcomes (such as survival or fewer complications) compared to those undergoing simultaneous resection. The narrow confidence interval suggests strong statistical reliability of this finding. Minimally invasive techniques showed comparable outcomes to open surgery, with acceptable morbidity rates (21.7%) even in simultaneous resections. Neoadjuvant chemotherapy with targeted agents achieved high resectability rates (97%) and significant response rates (66%). The presence of liver metastases negatively impacted immunotherapy efficacy, suggesting the need for tailored approaches. Management of sCRLM has evolved toward a more personalized approach incorporating advanced surgical techniques, targeted therapies, and novel treatment sequencing. While staged resection may offer advantages in selected cases, treatment decisions should be individualized based on patient and disease characteristics. Future research should focus on optimizing patient selection and treatment sequencing through prospective trials.

Simultaneous Resection of Colorectal Carcinoma and Hepatic Metastases is Safe and Effective: Examining the Role of the Robotic Approach

BACKGROUNDS AND OBJECTIVES

Up to 50% of patients with colorectal carcinoma (CRC) present with liver metastases (CLM) throughout their course. Complete resection of both sites provides the only chance for cure. Either a staged or simultaneous resection is feasible. The latter avoids delays in adjuvant systemic chemotherapy but may increase technical complexity and perioperative complications. We aim to evaluate our initial outcomes of simultaneous CRC and CLM resections with a focus on the robotic technique.

METHOD

With institutional review board approval, we followed 26 consecutive patients who underwent simultaneous/concomitant liver and colorectal resection. Major liver resection is defined as resection of ≥3 contiguous Couinaud segments. Data are presented as median (mean ± SD).

RESULTS

Patients were 64 (63 ± 14.0) years old. Body mass index was 29 (29 ± 5.7) kg/m². 54% of patients had prior abdominal operation(s). A majority of patients were >ASA class III (73%), underwent major liver resection (62%) with robotic approach (77%). In the robotic cohort, there were no unplanned conversions to open. Estimated blood loss was 150 (210 ± 181.8) ml. Total operative duration was 446 (463 ± 93.6) minutes. Negative margins (R0) were obtained in all patients. Postoperative complication of Clavien-Dindo≥3 occurred in three patients, including one requiring reoperation with end ileostomy for anastomotic leak. Length of stay was 5 (6 ± 3.5) days. Three patients were readmitted within 30 days after discharge, none for reoperation. There was no 90-day mortality.

CONCLUSION

Our cohort of concomitant CRC and CLM resection demonstrates safety and efficacy via both the open and robotic approach.

Which surgical strategy for colorectal cancer with synchronous hepatic metastases provides the best outcome? A comparison between primary first, liver first and simultaneous approach

BACKGROUND

There is no clear consensus about the best surgical strategy for patients with colorectal cancer (CRC) and synchronous liver metastases (SCRLM).

METHODS

Between 2009 and 2019, patients with CRC and SCRLM considered for curative treatment were included. Perioperative and follow-up data were analysed to examine the safety and survival outcomes of primary first (PF), liver first (LF) and simultaneous resection (SR) strategies.

RESULTS

204 patients were identified, consisting of PF (n = 129), LF (n = 26) and SR (n = 49). Forty-five patients (22.1%) failed to have either the primary or the liver metastases resected following initial LF (n = 11, 42.3%) or PF (n = 34, 26.4%), respectively (p < 0.001). The postoperative morbidity rates were 31.0%, 38.4% and 40.8% in PF, LF and SR group, respectively (p = 0.409); the mortality rates were 2.3%, 0% and 4.1%, respectively (p = 0.547). The 1-, 3- and 5-year overall survival (OS) were 94%, 72%, 53% in the PF group, 74%, 54%, 36% in the LF group, and 91%, 74%, 63% in the SR group. LF group had the worst OS compared to PF and SR (p = 0.040, p = 0.052). The 1-, 3- and 5-year disease-free survival (DFS) were 31%, 15%, 10% in PF, 21%, 9% and 9% in LF and 45%, 28% and 28% in SR group, respectively. SR group had a better DFS compared to PF and LF (p = 0.005, p = 0.008). At the multivariate analysis, there was no difference between the three strategies in terms of OS (PF vs SR OS-HR 1.090, p = 0.808; LF vs SR OS-HR 1.582, p = 0.365) and the PF had a worse DFS compared to the SR approach (PF vs SR DFS-HR 1.803, p = 0.007; LF vs SR DFS-HR 1.252, p = 0.492).

CONCLUSIONS

PF, LF and SR had comparable postoperative morbidity and mortality. The three surgical strategies had similar OS outcomes. The PF strategy was associated with a worse DFS than SR, while the LF approach was associated with a high failure rate to progress to the second stage (primary tumour resection).

Tumor enhancement of colorectal liver metastases on preoperative gadobutrol-enhanced MRI at 5 minutes post-contrast injection is associated with overall survival post-hepatectomy

Previous studies have demonstrated that target tumor enhancement (TTE) of colorectal cancer liver metastases (CRCLM) on 10-minute delayed phase gadobutrol-enhanced MRI is associated with overall survival post-hepatectomy. The purpose of this study was to determine whether TTE of CRCLM on preoperative gadobutrol-enhanced MRI measured at 5-minute delayed phase is also associated with overall survival. We performed a single-institution, REB-approved, retrospective study of 121 patients with CRCLM who had received a clinical gadobutrol-enhanced MRI after treatment with chemotherapy and prior to liver surgery between January 1, 2006 and December 31, 2012. The TTE of the colorectal liver metastases (CRLM) on 5-minute delayed phase was determined. Kaplan-Meier and Cox-regression survival analyses were used in order to determine the association between TTE on 5-minute delayed phase and overall survival, after adjusting for known prognostic variables. TTE of chemotherapy-treated CRLM on gadobutrol-enhanced MRI at 5-minute post-contrast injection is associated with overall survival post-hepatectomy. On Kaplan-Meier survival analysis, there was a significant difference in overall survival between strong and weak TTE groups (log-rank P=0.009) with 74.4% survival at 36 months in the strong TTE group compared to only 44.6% in the weak TTE group. On Cox-regression analysis, the adjusted hazard ratio of death for patients with low TTE was 0.40 (95% CI: 0.18-0.90, P=0.026), after adjusting for known prognostic variables. This study provides preliminary evidence that tumor enhancement of CRLM at 5 minutes post-contrast injection on gadobutrol-enhanced MRI may provide preoperative prognostic information. This may be helpful for risk stratification of patients for surgery.

Morbidity and mortality of synchronous hepatectomy with cytoreductive surgery/hyperthermic intraperitoneal chemotherapy (CRS/HIPEC)

Background

Liver resection in conjunction with partial colectomy for colon cancer is considered acceptable treatment for isolated metastasis to the liver. This method is unstudied in patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for carcinomatosis due to colon cancer and high grade appendiceal cancer.

Methods

A retrospective chart review included patients from 2005 to 2016 undergoing CRS/HIPEC. Cancers other than colorectal adenocarcinoma and high grade appendiceal carcinoma were excluded. Patients were divided into hepatectomy and non-hepatectomy groups. Data was collected by chart review from electronic medical records to assess morbidity and mortality, as well as oncologic outcomes of included patients.

Results

The average patient age, length of stay, and sex were similar between groups. For those in the hepatectomy group, 80% underwent minor hepatectomy, and 20% underwent major hepatectomy. The comprehensive complication index (CCI) scores ranged from 0 (no complications), to 100 (death). The average CCI between study groups was similar (27.29 vs. 17.41, P=0.09). Hepatectomy was associated with a higher rate of Clavien-Dindo classifications (CDCs) of III or greater. Complications included pressor requirement, renal failure, blood transfusions, TPN, pleural effusions and leaks requiring drain placement, respiratory failure, UTI, new onset atrial fibrillation, wound infections, and death.

Conclusions

Patients who underwent CRS/HIPEC and hepatectomy for colorectal and high grade appendiceal carcinomatosis had more severe complications at similar rates to non-hepatectomy patients. Complication rates should be considered when selecting patients for aggressive surgical intervention.

Delayed tumour enhancement on gadoxetate-enhanced MRI is associated with overall survival in patients with colorectal liver metastases

OBJECTIVES

To determine whether tumour enhancement on preoperative delayed-phase gadoxetate-enhanced MRI can predict long-term survival in patients with colorectal liver metastases (CRCLM) post-hepatectomy.

MATERIALS AND METHODS

Sixty-five patients who received a preoperative gadoxetate-enhanced MRI prior to liver resection for CRCLM from January 1, 2010, to December 31, 2012, were included in this retrospective study. Target tumour enhancement (TuEn) was calculated as the mean percentage increase in SNR from precontrast to 10-min or 20-min delayed phase for up to two target lesions. Per-patient TuEn was stratified into weak and strong enhancement based on the cut-off determined by the Youden Index for 3-year survival. Kaplan-Meier and Cox regression analyses were used to determine whether tumour enhancement could predict overall survival independent of potential confounders (clinical risk score).

RESULTS

The proportion surviving at 3 years was 85.1% in patients with strong TuEn at 10 min vs. 56.5% in those with weak TuEn at 10 min (p = 0.001). The proportion surviving at 3 years was 79.4% in patients with strong TuEn at 20 min vs. 58.7% in those with weak TuEn at 20 min (p = 0.011). After adjusting for potential confounders, the hazard ratio of death was 0.24 (p = 0.009) in patients who had weak TuEn at 10 min and 0.32 (p = 0.018) in patients who had weak TuEn at 20 min.

CONCLUSIONS

Strong delayed tumour enhancement seen on gadoxetate-enhanced MRI is associated with overall survival in patients with CRCLM post-hepatectomy and may be useful for preoperative risk stratification.

KEY POINTS

• Delayed tumour enhancement of colorectal liver metastases on gadoxetate-enhanced MRI is associated with survival post-hepatectomy • Delayed tumour enhancement of colorectal liver metastases on gadoxetate-enhanced MRI can be measured at both 10 min and 20 min post-contrast injection.

Shaping the future of liver surgery: Implementation of experimental insights into liver regeneration

Background

While liver surgery has become a safe and feasible operation technique, the incidence of postoperative liver dysfunction still remains a central problem. Approximately 10% of patients undergoing liver resection were shown to develop liver dysfunction, which is associated with an increased risk of morbidity and mortality. Yet, to date there is no effective treatment option for postoperative liver dysfunction available. The development of postoperative liver dysfunction was linked to a disruption in the liver's potential to regenerate. Thus, it is importance to elucidate the underlying mechanisms of liver regeneration and to find potential therapeutic targets for the treatment of patients with postoperative liver dysfunction.

Methods

A review of the literature was carried out.

Results

We report on potential future interventions for improvement of liver regeneration after surgical resection. Moreover, we evaluate the benefits and drawbacks of hepatic progenitor cell therapy and hematopoietic stem cell therapy. However, the most significant improvement seems to come from molecular targets. Indeed, von Willebrand factor and its pharmacologic manipulation are among the most promising therapeutic targets to date. Furthermore, using the example of platelet-based therapy, we stress the potentially adverse effects of treatments for postoperative liver dysfunction.

Conclusion

The present review reports on the newest advances in the field of regenerative science, but also underlines the need for more research in the field of postoperative liver regeneration, especially in regard to translational studies.